Provider Demographics
NPI:1548612039
Name:CERISANO, NICOLETTE (DDS)
Entity Type:Individual
Prefix:
First Name:NICOLETTE
Middle Name:
Last Name:CERISANO
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:
Other - First Name:NICOLETTE
Other - Middle Name:HOLLY
Other - Last Name:BOHN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DDS
Mailing Address - Street 1:12138 MUKILTEO SPEEDWAY # 301
Mailing Address - Street 2:
Mailing Address - City:MUKILTEO
Mailing Address - State:WA
Mailing Address - Zip Code:98275-5738
Mailing Address - Country:US
Mailing Address - Phone:425-347-4141
Mailing Address - Fax:
Practice Address - Street 1:12138 MUKILTEO SPEEDWAY # 301
Practice Address - Street 2:
Practice Address - City:MUKILTEO
Practice Address - State:WA
Practice Address - Zip Code:98275-5738
Practice Address - Country:US
Practice Address - Phone:425-347-4141
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-07
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADE606594951223G0001X, 122300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes122300000XDental ProvidersDentist
No1223G0001XDental ProvidersDentistGeneral Practice